Provider Demographics
NPI:1982136768
Name:HAFER, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HAFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 N HWY 89
Mailing Address - Street 2:STE C
Mailing Address - City:HARRISVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84404-2675
Mailing Address - Country:US
Mailing Address - Phone:801-393-3632
Mailing Address - Fax:801-393-4081
Practice Address - Street 1:19 W CENTER ST
Practice Address - Street 2:STE 201
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5804
Practice Address - Country:US
Practice Address - Phone:801-393-3632
Practice Address - Fax:801-393-4081
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker